Insurer Held Accountable for Misleading Explanation of Policy to Elderly Traveller
Insurer Held Accountable for Misleading Explanation of Policy to Elderly Traveller
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
An elderly gentleman, who submitted a claim on behalf of his injured wife, has successfully resolved his dispute against his insurance company.
The Australian Financial Complaints Authority ruled in favor of the complainant, finding that he had been misled into thinking he had coverage.
The claim was initiated after the man's wife had a severe fall down a flight of stairs during their trip to Thailand. She sustained multiple injuries, including a fractured hip and head trauma, which required her to be hospitalized for more than three weeks. Additionally, to ensure a safe journey back to Melbourne, the claimant had to purchase a business class flight for his wife, allowing her to lie flat and minimize the risk of complications.
Zurich Australia denied the claim based on the policy's exclusion of overseas medical expenses for individuals over 80 years old. However, Zurich claimed to have offered an "upgrade" to the policy, providing medical coverage for individuals over 80, which the claimant did not opt for.
The complainant obtained the policy through a local branch of his bank, referred to as CB, which offered it as a benefit for specific credit card holders. At the time of purchasing the policy, both the complainant and his wife were 81 and 80 years old, respectively.
Making an effort to follow the correct procedure given his limited computer skills, Mr. E visited the local CB branch on June 30. He expected the staff to guide him through the application process for the policy.
Mr. E alleged that the CB staff failed to inform him about the need to "upgrade" the policy in order to ensure adequate coverage for medical expenses. He left the bank under the impression that he and his wife were appropriately insured, even receiving an email confirmation from the insurer stating that the policy had been activated.
AFCA considered the claimant's assertion that a bank teller, referred to as SH, had assisted him during the application process. Despite Zurich's objections, the ruling ombudsman agreed with Mr. E's account.
The ruling acknowledged that SH had neglected to disclose the requirement to "upgrade" the policy, necessary for the claimant and his wife to have coverage, despite the bank being aware of their age. It stated that although SH's actions were unintentional, CB caused the insured party to believe they had suitable coverage.
"Given CB's knowledge of the complainants' age, this omission should have been disclosed," AFCA stated.
"SH's oversight significantly contributed to Mr. E's unwitting failure to apply for the policy upgrade. Furthermore, this omission induced Mr. E to enter into an insurance contract that he believed provided adequate coverage. However, unbeknownst to him, the policy was essentially useless in terms of overseas medical expense coverage for both him and Mrs. E."
Zurich argued that CB employees were not authorized representatives and thus were unable to offer any advice on the credit card insurance being offered. However, AFCA dismissed this argument as an attempt by the insurer to absolve itself of CB's shortcomings, stating that the bank acted, at least partially, in the insurer's interest.
The decision mandates that Zurich accept the claim and provides a compensation of $4000 ($2000 for each complainant) for non-financial losses resulting from the insurer's claim denial and subsequent challenges.
"Throughout the claims process, the insurer's stance has unfortunately caused the complainants, particularly Mr. E, to feel accused of dishonesty," expressed AFCA.
"They also feel that their recollections have been questioned. Moreover, the insurer's position in this claim has been based on flimsy evidence."
Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.
Recent transport industry coverage has again highlighted regulator attention on heavy vehicle roadworthiness, with roadside checks, defect management and maintenance systems remaining central safety themes for Australian operators. For trucking businesses, the message is not limited to avoiding fines or delays. Roadworthiness can also influence how insurers view risk, how smoothly a claim progresses and whether policy conditions have been met after an incident. - read more
Australia’s engineered stone ban and continuing regulator focus on silica exposure are more than a workplace safety issue for builders, renovators, tilers, stonemasons, plumbers, electricians and demolition contractors. They also create a practical insurance checkpoint for any trade business that cuts, drills, grinds, removes or works around dust-generating materials. - read more
Fresh motor insurance commentary across the Australian market is again pointing to a practical issue truck operators know well: repairing vehicles is becoming more complex, more expensive and, in some cases, slower. For heavy vehicle businesses, this is not just a workshop problem. It can influence claim outcomes, renewal pricing, excess settings and the amount of time a truck is off the road after an incident. - read more
Recent complaints data from the Australian Financial Complaints Authority has again highlighted a pressure point that matters to rural Australia: insurance claims can become difficult when expectations, policy wording and evidence do not line up. While the figures cover the wider insurance market rather than farms alone, the themes are highly relevant for agricultural businesses dealing with storm damage, fire losses, machinery failures, fencing repairs or interrupted operations. - read more
Fresh industry attention on ASIC's expectations for compensation arrangements is a timely reminder that professional indemnity insurance should not be treated as a once-a-year renewal task. For Australian professionals who provide advice, compliance support, financial services, consulting, design, technology or outsourced business services, the adequacy of cover depends on how closely the policy matches the work actually being performed. - read more
When it comes to life insurance, a pre-existing condition refers to any medical condition or illness that you have been diagnosed with before applying for a life insurance policy. - read more
For many millennials, navigating the complexities of personal finance and future planning can feel like a bewildering journey. Among these financial responsibilities, life insurance emerges as a paramount consideration. More than just a safety net, life insurance can be the cornerstone of a sound financial strategy, providing peace of mind for both the policyholder and their loved ones. - read more
When you’re young, life is all about new experiences and making plans for a promising future. While factors like travel, career, and relationships often take centre stage, one aspect often overlooked is life insurance. It might seem like something to consider later in life, but starting a policy while you're young can be a savvy financial move. - read more
Many Australians hold life insurance through their super fund, sometimes without realising how it differs from a policy held outside super. This guide explains how insurance inside super works, how premiums and beneficiaries are handled, and what to check before relying on it. - read more
Life insurance is a crucial part of any comprehensive financial plan, providing peace of mind that your loved ones will be financially secure in the event of your passing. - read more
Start Here !
Apply now for your free Insurance assessment and price comparisons!
Knowledgebase
Claim Adjuster: An insurance professional who investigates and evaluates insurance claims to determine the amount the insurance company should pay.
No comments yet. Be the first to share your thoughts.